International AIDS Conference: Circumcision Does Not Protect Against HIV Infection

Presentation at the 16th International AIDS Conference in Toronto
By Danny Kucharsky

HIV prevalence is not lower in populations that have higher male circumcision rates, according to findings from a study of African countries presented in Toronto at the 16th International AIDS Conference (AIDS 2006).

The study, which examined the association between male circumcision and HIV infection in 8 Sub-Saharan African countries, contradicts the findings of previous research and the opinion of several prominent personalities active in the fight against AIDS, such as former US President Bill Clinton and Bill Gates (founder and CEO of Microsoft).

While three studies have suggested male circumcision has a protective effect against sexually transmitted infections (STI), including HIV infection, the evidence is inconclusive, said investigator Vinod Mishra, MD, director of research, ORC Macro, Calverton, Maryland. "We're just questioning that push," he said of the optimism displayed by Clinton and others.

The study used demographic findings from recent demographic and health surveys in Burkina Faso, Cameroon, Ghana, Kenya, Lesotho, and Malawi, and AIDS indicator surveys from Tanzania and Uganda. The surveys were conducted from 2003 to 2005 and sample sizes ranged from 3,300 men in Lesotho to 10,000 men in Uganda.

In survey fieldwork in each country, men aged 15 to 59 gave blood for anonymous HIV testing. Information on circumcision status and on STI/STI symptoms was based on men's responses to questions in survey interviews.

Prevalence of male circumcision ranged from a high of 96% in Ghana to a low of 21% in Malawi. Among the other countries, circumcision rates were 84% in Kenya, 89% in Burkina Faso, and 25% in Uganda.

HIV prevalence was lower among circumcised than intact men only in Kenya (11.5% among intact men vs 3.1% among circumcised men). A small, statistically insignificant difference was also seen in Burkina Faso (2.9% vs 1.7%, respectively) and Uganda (5.5% vs 3.7%).

In each of the other countries, there was either no difference in HIV rates between circumcised and intact men, or circumcised men were more likely to be HIV-positive than intact men. For example, in Lesotho, HIV was seen in 23.4% of circumcised men compared with just 15.4% of intact men.

"If anything, the correlation [between circumcision and HIV infection] goes the other way," in most of the countries studied, Dr. Mishra said during his presentation on August 15th.

When adjusted for sociodemographic and behavioral factors, the difference in HIV infection was not statistically significant in any country, Dr. Mishra said.

In Kenya, and to a lesser extent, in Ghana, Malawi, Tanzania, and Uganda, circumcised men were less likely than intact men to report having had an STI, or STI symptoms, in the 12-month period prior to the survey (2.1% vs 5.4%, respectively). The relationship was reversed in Cameroon (8.0% vs 2.5%) and Lesotho (12.1% vs 7.5%).

With other factors controlled, the theorized "protective" effect of male circumcision was statistically significant only in Tanzania.

In addition, "circumcised men tend to have more lifetime sex partners, so there's some [high-risk] behaviors that go with circumcision status," he said.

A study limitation is that it was based on self-reported information on circumcision status and STI/STI symptoms. It also lacks data on age at circumcision and degree of circumcision, which might influence susceptibility to HIV infection.

However, Dr. Mishra said the study is consistent with other research that has failed to find a protective effect of male circumcision on HIV and STIs (sexually transmitted infections).